How Nutrition Plays a Role in Wound Healing

Kelsey L. PuffeConcordia College, Moorhead,

MNSeptember 25, 2008

Objectives:

Be able to describe pressure ulcers Identify contributing factors to

development of pressure ulcers Identify the different stages of

pressure ulcers Identify recommended treatment

and nutritional treatment for pressure ulcers

Bed Sore or Pressure Ulcers

Pressure Ulcers- begin as tender, inflamed patches that develops when a person’s weight rests against a hard surface, exerting pressure on the skin and soft tissue over bony parts of the body. 95% develop on the lower part of the

body

Skin Problems & Treatments Health Center: Pressure Ulcers (2007): 15 Sept. 2008 http://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores

Cause This is most likely to happen when the

person is confined to a bed or wheelchair for long periods of time and is relatively immobile. Constant pressure on the skin and tissues Sliding down in a bed or chair, forcing the

skin to fold over itself Being pulled across bed sheets or other

surfaces Moisture that stays on the skin

Stage 1 of Pressure Ulcers The National Pressure Ulcer Advisory Panel (NPUAP)

recommends classification of bedsores in 4 stages of ulceration based primarily on the depth of a sore at the time of examination.

Stage 1: Intact skin with redness (erythema) and sometimes with warmth

Stage 2

Partial-thickness loss of skin, an abrasion, swelling, and possible blistering or peeling of skin

Stage 3 Full-thickness loss of skin, open wound

(crater), and possible exposed under layer.

Stage 4

Full-thickness loss of skin and underlying tissue, extends into muscle, bone, tendon, or joint. Possible bone destruction, dislocations, or pathologic fractures (not caused by injury).

A doctor should be notified whenever a person:

Will be bedridden or immobilized for an extended period of time

Is very weak or unable to move Develops redness (inflammation) and warmth or

peeling on any area of skin

Progression

Common Places for Pressure Ulcers

Bony parts of the body Ankles Back of the Head Heels Hips Knees Lower Back Shoulder Blades Spine

How to prevent pressure sores

Prevent constant pressure on any part of the body.

Change positions Turn often to reduce constant pressure

on skin Learn the proper way to move yourself

to avoid folding and twisting skin layers Spread body weight Cushions, pad metal parts of

wheelchair GOOD NUTRIENT INTAKE IS

ESSENTIAL Barrier lotions or creams that have

ingredients that can act as a shield to help protect the skin from moisture and irritation

Immediate medical attention is required whenever: Skin turns black or becomes inflamed, tender,

swollen, or warm to the touch The patient develops a fever during treatment A bedsore contains pus or has a foul-smelling

discharge

Risk Factors for Impaired Healing Advanced age Diabetes Impaired immunity Underweight Obesity Malnutrition Medications Infections Moisture Cognitive impairment/ altered sensory

perception

Who is typically affected? Older people and individuals with spinal cord

injuries Malnutrition, immobility, pressure, shear forces,

friction, sensory perception, and skin exposure to moisture can contribute to pressure ulcer incidence

Bed-Bound Paralyzed Elderly patients undergoing treatment for other

diseases Poor physical function, less able to perform self-

care, less mobile

Statistics

One million people in the United States develop bedsores at a treatment cost of $1 billion

Two thirds of all bedsores occur in people over age 70 Pressure sores have been noted as a direct cause of death in

about 8% of paraplegics 1992, Federal Agency for Health Care Policy and Research

reported that bedsores afflicted 10% of all hospital patients 25% of nursing home residents 60% of quadriplegics

Bedsores (2007): 15 Sept. 2008 http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html

Concerns The number one concern

is MALNUTRITION Misdiagnosis Care can be very costly

and lengthy for patients and hospitals- Increases nursing care time by 50%- Prolonged hospitalizations - 90% recurrence rate- Higher hospital costs- Costs increase as pressure ulcer stage advances

Consequences

Cellulitus- acute infection of connective tissue

Bone and joint infections Necrotizing fasciitis- destroys tissues

around muscle

Gas gangrene Sepsis- blood infection

Cancer

Ethical Issues Knowing that Pressure Ulcers are preventable Nutrition Intervention is a great approach Knowledge of how to prevent and treat Pressure

Ulcers Recognizing that hospitalized and wheelchair

people are more susceptible to Pressure Ulcers Reluctance of health care providers to diagnose

Pressure Ulcers & at a early enough stage Don’t want to take the blame for development Increasing demands of healthcare intervention

accountability by legal professionals

Treatment

Focuses on preventing a sore from getting worse and on making the skin healthy again Relieving pressure on the area by changing

positions often and spreading body weight evenly with special mattresses

Keeping the sore clean and covered, not letting it dry out

Eating a healthy diet with enough protein to help the skin heal

Keeping healthy tissue around a pressure sore clean and dry

Removing dead tissue and applying medicated ointments or creams to reduce the risk of infection.

Treatment

Most stage 1 and 2 pressure sores will heal within 60 days with proper treatment

Stage 3 and 4 can take months or even years to heal

Progress is slow, continued care and treatment can prevent complications such as further tissue damage, infection, and pain

Home Treatment

Use cushions Use sheepskin layers or foam alternatives on chairs and beds At least every 2 hours, reposition yourself Avoid using doughnut-type devices or boots fill with air to

support heals Keep yourself active Inspect skin daily, learn to recognize what a pressure ulcer is Keep skin clean and free of sweat, wound drainage, urine, and

feces Moisturize skin with lotion, limited exposure to dry cold

weather Provide good nutrition through a healthy diet with enough

protein to keep skin healthy and able to heal more quickly Maintain a healthy weight

“Effective nutritional assessment and subsequent support are essential to the prevention and treatment of

pressure ulcers.”Marti Andrews, PhD, RD

Laboratory Values Serum albumin < 3.5

mg/dL Prealbumin < 16

mg/dL Hematocrit < 33% Hemoglobin < 12 g/dL Transferrin < 100

mg/dL Serum Cholesterol <

160 mg/dL

Weight: >5% in 30 days, or >10% in 180 days

Fluid intake less than 1,500 ml/24 hours over past seven days

Total lymphocyte count <1800 mm

BUN/ Creatinine > 10:1

Nutrition Care

Patient screening and assessment Nutrition Intervention Monitor Reassess

Nutrition Goals

Provide adequate calories Prevent/Treat protein-calorie

malnutrition Promote wound healing Provide adequate macro and

micronutrients during all stages of the wound-care process

Healing Foods Pyramid- Recommended Servings

Water:64 to 96oz daily Fruits: 2 to 4 servings daily Vegetables: 5 servings daily Grains: 4 to 11 servings daily Legumes/soy: 2 to 5 servings daily Healthy Fats: 3 to 9 servings daily Seasonings: a variety of spices & herbs daily Dairy:1 to 3 servings, emphasizing low-fat choices daily Eggs: up to 1 daily Fish & Seafood: 2 to 4 servings weekly, emphasizing a high omega-3 fatty

acid intake Lean Meats: 1 to 3 servings weekly Alcohol: up to 2 servings daily Dark Chocolate: up to seven oz weekly Tea: 2 to 4 cups daily

Bareuther, Carol M. Food to Help You Mend. Today's Diet &Nutrition (2007): 34-37.

Calories Poor calorie intake is associated with poor protein, vitamin and

mineral intake. Calories equal energy and it takes a lot of energy to heal a

wound. Eat enough calories to “spare” the use of protein for energy. Calories in your diet should come from a variety of “healthy

sources” 30 kcal/kg to 35 kcal/kg body weight

Lean meat Beans Legumes Whole grains/cereals Milk and milk products Fruits Vegetables

Basic Principles—CHO & Energy

Carbohydrate 55-60% of diet Provide as complex CHO

Glucose is the main energy source for cells Give insulin for glucose >250 mg/dL and decrease

intake if severe hyperglycemia Energy May need to increase calorie intake by 50% or more

depending on the severity of the wound. Minimum of 30-40 kcals/kg/day Use the Harris-Benedict formula to figure the energy

need

Basic Principles--Protein 20-25% of diet from protein The “building blocks” for tissue and wound repair. Is involved in the making of cells, enzymes (for chemical

reactions) and building connective tissue. Increased protein intake decreases the net nitrogen losses by

increasing the amino acid flow into the protein synthesis channel

1.2g to 1.5g of protein/kg body weightStage I- 1.0 g/kgStage II- 1.0-1.2 g/kgStage III- 1.25-1.5 g/kgStage IV- 1.5-2.0 g/kg

Foods that are good sources of protein All meats, Cheese, Cottage Cheese, Milk, Dry Milk Powder, Instant Breakfast,

Egg, Beans, Pudding/custard, Peanut butter, Yogurt, Ensure HP, Boost

MeritCare

Basic Principles--Fat

25-30% of diet Essential for cell membranes and

required for the absorption and function of fat-soluble vitamins

Fatty acid deficiency disrupts skin integrity

Need to keep triglycerides in check

Basic Principles--Fatty Acids/Omega 3 Type of polyunsaturated fatty acid Essential fat because the body cant make it Proper brain growth and development An anti-inflammatory Regulate mood by increasing serotonin

levels Recommended 2 to 3 oz servings of fatty

fish per week Cold water fish, wild game, walnuts, leafy

greens, canola oil, flaxseed

Basic Principles -- Micronutrient Support

Vitamin A Important for maintaining healthy skin and

mucous membranes Plays a important role in our immune system RDA is 5000 iu In wound healing- take 3- 4 times the

recommended RDA for 1-2 weeks Tomato Juice, Apricots, Cantaloupe, Nectarine, Green Beans,

Broccoli, Carrots, Squash, Brussels Sprouts, Yams, Sweet Potatoes

MeritCare

Basic Principles - -Micronutrient Support

Vitamin C Plays an important role in the formation of collagen

and cell production RDA is 60 milligrams Daily supplement of 500mg may be beneficial if a

patient is deficient in Vit. C or has pressure ulcers In wound healing- requirement is much greater.

May be advised to take additional vitamin C in a pill form.

Orange Juice, Cranberry Juice, Honey dew, Tangerine, Brussels sprouts, Grapefruit, Kiwi fruit, Strawberries, Broccoli, V-8 Juices

MeritCare

Basic Principles - -Micronutrient Support Calcium

A cofactor for some collagenases during remodeling

Necessary for normal blood coagulation Dietary Nucleotides

Building blocks for DNA/RNA Improve immune function Assist in wound healing Found in any animal protein

Basic Principles - - Micronutrient Support

Vitamin E Important role as an “anti-oxidant” Anti-oxidants help to protect cells from destruction In wound healing- role in reducing atherosclerosis (heart disease) RDA is 10mg for men & 8mg for women To much may interfere with wound healing

Unprocessed whole grains, vegetable oils, margarine, salad dressings, nuts, poultry, fish, seeds, and eggs

Copper Involved in making of red blood cells, absorption and

transportation of iron, wound healing, RNA synthesis and making of collagen

RDA is 1.5-3.0mg/day Legumes, seafood, shellfish, whole grains, nuts, seeds, and

vegetablesMeritCare

Basic Principles - -Micronutrient Support

Zinc Involved in over 200 enzyme systems,

functions of the immune system, heals wounds, enhances ability to taste food

Necessary for metabolism of protein Toxic if too much RDA is 12-15mg Can safely take up to 50mg daily for a 3

month time period to assist with wound healing

Seafood, meats, whole grains, milk & milk products, legumesMeritCare

Basic Principles - -Micronutrient Support

Magnesium Involved in 300 enzyme systems Important for protein metabolism Low levels can occur with diuretics, vomiting, diarrhea, stress on the

body Important in glucose and blood pressure control RDA is 280-350mg

Unprocessed whole grains, legumes, buts, chocolate, dark green vegetables, and bananas

MeritCare Iron

Involved in the electron transport chain, oxidative burst in phagocytosis, part of hemoglobin which transports oxygen to tissues

Inadequate iron decreases oxygen delivery to tissues & impairs the ability of leukocytes to kill bacteria, increasing risk of wound infection

RDA is 8mg/day for men and postmenopausal women, 18mg/day for premenopausal women

Iron supplementation should NOT be given to individuals with an active infection-can make it worse

Bacteria will use the iron-making it more difficult to fight the infection

Basic Principles- -Micronutrient Support Arginine

Plays a role in lymphocyte production, RNA synthesis, collagen disposition, improved tensile wound strength, and bacterial killing by macrophages.

17 to 24g/day for two weeks will improve the wound strength and collagen deposition in artificial wounds

Still need to meet energy and protein needs Not for everyone especially those with renal and liver

dysfunction.

Kline, Dale A. Healing From the Inside Out. Today’s Dietitian (2008): 12-17.

Basic Principles- - Micronutrient Support Glutamine

Plays a central role in many of the metabolic pathways involved in wound healing- acting as a building block or substrate for many rapidly proliferating cells in the healing process

RDA is 0.57g/kg of body weight/day in divided doses

Should NOT be given to people with renal or liver impairments

Basic Principles- - Micronutrient Support

Fluids Too little fluid impairs wound healing-same as too much Dehydrations reduces the supply of oxygen & nutrients to

the wound Over hydration compromises the integrity of the skin and

slows the inflammatory phase of wound healing RDA is minimum of 1,500mL or 30mL/body weight or

an amount equal to kilocalorie requirements Water acts as a solvent for minerals, vitamins, amino

acids, glucose-enabling them to diffuse in and out of the cells

Water transports vital materials to cells and waste away from cells

Maintains blood volume

Guidelines: < 10% Wt. Loss Uncomplicated Stage 1 & 2 Daily high potency vitamin-mineral 20% above RDA Vitamin C= 500mg Vitamin A= 5000IU Zinc sulfate = 220mg Weekly weight Weekly wound healing measurements DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care.

2000 Jan-Feb; Volume 13, Supplement 1: 11-20

Guidelines: < 10% Weight loss Healing Stages 3 & 4

2 high potency vitamin-minerals > 1.5g/kg a day (with a protein

supplements) Vitamin C = 1g a day Vitamin A = 400 IU Zinc sulfate = 220mg Weight weekly Weekly wound healing measurement DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care. 2000 Jan-Feb;

Volume 13, Supplement 1: 11-20

Guidelines: > 10% Weight Loss On going Catabolism Calories: 35-40 kcal/kg/d Protein: 1.5-2.0g/kg/d Glutamine: 10-20g/d Zinc sulfate: 220 mg Oxandrolone: 10 mg Weekly weight and wound

measurements DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound

Care. 2000 Jan-Feb; Volume 13, Supplement 1: 11-20

Standards of Practice

Nutrition Monitoring Weight Laboratory Values Calorie, protein, fluids, and proper

nutrient intake Wound healing

In Summary Pressure Ulcer is an area of the skin that breaks

down when you stay in one position for too long without shifting your weight.

Prevention Monitor your Nutrition Be active If you need to sit or be on bony parts of your body for a long time

make sure its cushioned To treat pressure ulcers relieve pressure regularly

Don’t sit or lie on the sore Use pillows & cushions Cleaning the sore regularly See a doctor Proper nutrition

Questions

References

Bareuther, Carol M. Food to Help You Mend. Today's Diet &Nutrition (2007): 34-37.

Bedsores (2007): 15 Sept. 2008 http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html

DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care. 2000 Jan-Feb; Volume 13, Supplement 1: 11-20

Dorner, Becky. Medical Nutrition Therapy for Pressure Ulcers. Medical Nutrition Therapy for Pressure Ulcers (2005): 1-9. Science Direct. Concordia College.

Dorner, Becky. NPUANewly Revised Pressure P's Ulcer Staging System. Today's Dietitian (2007): 24-25.

Fleishman, Amy. Adult Wound Care. Today's Dietitian 7 (2005): 38-42. Science Direct. EBSCO. Concordia College, Moorhead. 17 Sept. 2008.

Hurd, Theresa. Nutrition and Wound-Care Management/Prevention. Wound Care Canada 2: 20-24. Science Direct. EBSCO. Concordia College, Moorhead. 17 Sept. 2008.

American Dietetics Association."Nutrition Guidelines for Pressure Ulcers." Kline, Dale A. Healing From the Inside Out. Today’s Dietitian (2008): 12-17.

References

Krasner, Diane. Chronic Wound Care. Baltimore: Health Management Publications, 1990. 189-212.

Lewicki, Linda & et al. (1997). Potential Risk Factors for Pressure Ulcers During Cardiac Surgery. AORN Journal, 65. 933-942.

Mackay, Douglas, and Alan L. Miller. "Nutritional Support for Wound Healing." Alternative Medicine Review 8 (2003): 359-377. Elsevier. EBSCO. Concordia, Moorhead. 17 Sept. 2008.

MeritCare. “Nutrition and Wound Healing.” Sollinger, Christine. “Pressure Ulcers.” Today’s Dietitian (1999): 31-34. Skin Problems & Treatments Health Center: Pressure Ulcers (2007): 15 Sept. 2008

http://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores 3M Innovation. Skin Health: A 3M Guide to Understanding Pressure Ulcers. 1998.

References Pictures

www.selectmedical.co.uk/images/Shop/pug.jpg www.usc.edu/.../pups/images/stages/stage1.gif http://www.revolutionhealth.com/articles/stages-of-pressure-sores/

zm2442 http://catalog.nucleusinc.com/generateexhibit.php?ID=9476 www.answers.com/topic/bedsore www.napnes.org/etraining/courses.php jama.ama-assn.org/cgi/content/extract/296/8/1020